This Angel is pissed off. I'm Nurse Anne and I work on large general medical ward in the NHS. These are the wards with the most issues surrounding nursing care. The problems are mostly down to intentional understaffing by hospital chiefs that result in a lack of real nurses on the wards.
"The martyr sacrifices themselves entirely in vain. Or rather not in vain, for they merely make the selfish more selfish, the lazy more lazy and the narrow more narrow"-Florence Nightengale

Tuesday, 18 September 2007

Why are so many nurses getting away from nursing?

Most journalists (especially the ones who write about hospitals) are morons. Occasionally Journalists do get stuff right. I have stumbled upon a couple of articles that demonstrate this rare phenomenon. Both of the articles I am posting here are American but the things they are talking about apply to UK nurses as well. I wish the British media would do this.

We have the same problems occurring on both sides of the pond in completely different health systems. I have worked in both the USA and the UK as an RN and I have always said that there are more similarities than differences...this is especially true when it comes to nursing. On both sides of the pond healthcare has been enslaved by the almighty dollar (or pound). The people running the hospitals do not see nurses as educated professionals who are crucial to patient safety. They see nurses as an expense that they want to do away with.

They will happily send a ward nurse an unstable patient who needs her constant presence at their bedside to survive the shift on top of 20 other patients who all need massive amounts of care. They will then refuse to send her another nurse or any kind of help citing money as the main problem. They know that people will assume that the shitty care those other 20 patients have received are a result of horrible lazy nurses. They won't have angry relatives screaming at them...the overwhelmed nurse will have that while she is busy trying to get blood hung on the guy with the GI bleed. If a patient was harmed in that situation do you know who the law would go after? The nurse. Fact.

Many good nurses have lost their registration due to situations like this one. The boards of nursing in the USA and the NMC here in the UK have taken an interesting stand on these situations. Their view is that a nurse is a professional and that if she agrees to take on a dangerous amount of acutely ill patients than she is liable. Completely. Their advice to us is that we need to get away from an employer who won't staff properly or we are liable and they will take our pin numbers so that we can never work in healthcare again. I have a written letter from them stating this. Their advice was to refuse a dangerous assignment as it is better to get fired and anger your manager rather than end up in court.

There are three problems with this stand by our nurse licensing organisations: first of all nurses have families and mortgages and financial commitments and can't just pack in their jobs. The second problem is that the UK has a complete recruitment freeze going on at the minute and there are NO JOBS. NONE. Most of our new grad nurses are unable to find employment. The third problem is that if you do take a stand and refuse to take on a dangerous assignment you will not only lose your job but get blacklisted and never get another. I have seen them give bad references and take disciplinary action against a nurse because they have refused to be the only nurse on a 30 bed ward. Two of these nurses are currently on the dole.

There is nothing forcing the managers to staff the wards safely. Nothing. This is why everyone is getting the hell away from the bedside. If you think they are getting out and going quaktitioner because they are too posh to clean up faeces and simply want to advance and get more pay you are mistaken. It's the impossible the workloads and the liability that are causing the nurses to flee. Nurses love nursing they just don't like abuse. More nurses are escaping the bedside completely by leaving healthcare all together. A very very small number are going into "advanced roles". If you go to feed that patient or clean up the other one who is lying in filth the time you spend away will kill one of your other patients. Patients weren't as unstable years ago. People like this died quickly and back then it was accepted.

I am hoping that British journalists will talk to nurses who are CURRENTLY working in our hospitals. I want to see them do research rather than the usual "nurses don't wash their hands and leave you in your own filth because they are mean" tabloid rubbish. I want our hospitals to improve. This is never going to happen until people in general realise that nurses are important and that we need lots of them. We already KNOW that having more nurses saves more money than it costs because of the reduction in expensive patient complications as well as inpatient stays. I am talking about Registered Nurses here...not the minimum wage paid housekeeper who was taught how to take a blood pressure and wears a uniform nearly identical to mine.

Nurses who have left nursing have said that it is going to take less patients and better working conditions to get them back into the profession. Having to clean up shit and puke are the least of our worries and the easiest part of the job really.

Our abhorrent salaries are the least of our worries.

Simply paying more money to nurses isn't going to fix anything.

In the USA an RN who has just qualified (including diploma and associate degrees) start at a salary of about $50,000-$55,000. In some places it is up to $60,000-$70,000. This is far higher than the salary that most university graduates obtain in the beginning. . Nurses earn more than policemen, social workers, and teachers. There is a lot of room to grow and it's fairly easy to bring in a 6 figure salary annually if you pick up lots of overtime. Nurses in the UK are banned from overtime right now and mandatory over time is completely unpaid. But even with a decent salary and wickedly awesome overtime pay USA hospitals cannot retain their nurses.

"In nursing, pay isn't the only issue. Difficult working conditions and understaffing also deter qualified people from pursuing the profession (see BusinessWeek.com, 8/21/07, "Labor Shortages: Myth and Reality"). But average annual wages for registered nurses (one of the most highly trained categories) is now just under $58,000 a year, compared with a $36,300 average for U.S. workers overall. And it's clear that qualified American nurses see that as not enough: There are 500,000 registered nurses who are not practicing their profession—fully one-fifth of the current RN workforce of 2.5 million and enough to fill current vacancies twice over."

"While nurses' advocates say better pay is critical, they also argue that working conditions must improve if the U.S. is to cultivate an enduring nursing workforce. Future projections of staffing troubles are ominous. The current 8.5% shortage is expected to surge to 29%—or more than 810,000 nurses—by 2020, according to the U.S. Health & Human Services Dept. "You will draw in some people with a good pay raise, but you won't necessarily get them to stay," says Cheryl Johnson, a registered nurse and president of the United Association of Nurses, the largest nurses' union in the U.S. "Almost every nurse will tell you that staffing is a critical problem. The workload is so great that there's not time to see how [patients are] breathing, give them water, or turn them to prevent bedsores. The guilt can be unbearable."

You wouldn't even believe the figure of qualified British nurses who are living in Britain and refusing to work as nurses so I won't post it. The hospitals would refuse to hire them anyway. They want the registered nurses out.

Basically the Americans are paying their nurses more money and still nurses who love nursing don't want to do it. In the UK we are paying them absolute shit and yet nurses who love nursing don't want to do it. Check out some of the comments on that article. Could have been written by any nurse at my hospital.

Experienced well educated nurses who are dedicated to nursing are leaving the profession in droves and their managers are loving it. We train more nurses and they (well the ones who can find a job anyway) burn out quick. We burn them out faster than we can train them. What the fuck is going on? The bottom line is that healthcare revolves around money and nurses are seen as a cost. The powers that be don't even really know what a nurse does or what they are responsible for. They don't understand the outcomes that patients have when there are too few nurses. To these guys nurses are just a part of a budget that needs to be reduced. An inexperienced nurse is cheaper. A foreign nurse who can't speak english is cheaper and more likely to take abuse and accept dangerous workloads because he/she doesn't understand the law.

I have so many sick patients and I'm so scared that I am often throwing up before work due to nerves. I am not the only one at my hospital who feels this way. We have so many patients we can't even remember all of their names and medical problems. The whole shift becomes a rat race trying to run from one task to the next with constant interruptions. I can easily be halfway through 18 jobs at any given time. Then the consultant shows up to do rounds and wants information from me on people who I haven't even seen. Haven't even been able learn about them. Forget about being able to look in their notes or spend any time with them at any point during your 15 hour shift. We are not nursing we are putting out fires all day. Ninety-nine percent of us want to do real nursing. Most of us working today trained in the "the good old days".

Sometimes people stop breathing at mealtime. Sometime post-op patients come back to the ward at mealtime. Sometimes patients have a seizure at mealtime. Sometimes 8 people need pain killers at mealtime. Lots of times all this happens all at once at mealtime. There is no one to feed my other 12 patients who are unable to feed themselves. I am then accused of "letting people starve because I can't be bothered with real nursing care". Had I let any of that stuff go and fed my patients first I would be in court real fast. We rarely have doctors on the wards as they don't have ward based doctors at my hospital so it's not like they can do CPR while I feed everyone.

We ask management to please allow us to have help at mealtime. They have literally (oh yes) responded with "piss off". No they are not running around trying to get nurses in because they care about patient care. Quite the opposite in fact. These bastards don't even understand the link between staffing and patient care. I'm sure our chief executive doesn't understand the difference between a nurse and a porter. They want to save money.

So so afraid someone will die because I can't be 10 places at once and I will be charged with manslaughter. This is not an unreasonable fear but a very valid one. This was confirmed for me after I spoke to the NMC and an attorney who was once a nurse. The people who refuse to send any staff will have no comeback and that is the truth. It makes me so angry.

More patients+ more patients with increasingly complex problems+less nurses due to intentional short staffing = horrible care and nurses getting a bad reputation. They get verbally and physically abused. They become burned out. We are losing more bedside nurses to this than anything. Would an abused wife stay in a marriage where her husbands beats her if someone offers her more money?

What would happen of all the burned out nurses who left the beside decided to come back and work? Would that fix the problem? Nope. The hospitals wouldn't hire them. They don't want them. They don't want the new grads either. There are no jobs in the UK and they are getting harder to find in the USA. It's just one big roaring nightmare and I don't know how to make these people listen.

13 comments:

Nurse Anne - I have been following your comments [here, and on other threads] with great interest.

To my mind working on an acute medical ward is the hardest job in nursing, PERIOD - you have already made it abundanly clear why this is so.

From my own experience I know that medical nursing was a hard, backbreaking job 10yrs ago but you are so right to point out the huge increase in throughput [and patient acuity] that has occurred even during the last decade.

Sadly you are also absolutely correct when you mention that currently, there is no mechanism in place to force the issue on nurse:patient ratios [despite the best efforts of Zarathustra/Beakie & Co - if you haven't read mental nurse may I commend it to you].

For example, I imagine it must be far easier for the NMC to jump on a few nurse cowboys rather than address the structural issues of poor practice at a more fundemental level.

If nursing bodies cannot get this right, while continuing with a policy that leaves front line staff hanging out to dry, then I don't think we can expect too much from ghastly rags like the Sun.

No, the Sun can only portray nurses in one of three ways;Heroes, for example after the tube bombing.Villains: patients left rolling in shit on MRSA infested wards.Or as a tarty sexual sterotypes [and occassionally as Hattie-Jacques-type-characters, I suppose].

Bizarrely many doctors seem to persist with the similar stereotypes - perhaps too many doctors are reading the Sun ?

I must be honest and say that staffing levels have actually gone up in our department.But this is not because managers are concerned about staff moral, or standards of patient care come to think of it.

Guess what, the hospital is striving for "Foundation" status and one of the qualifying criteria is to ensure that A&E hits 98% when it comes to the 4hr wait - and they wonder why one two of us become rather cynical.

A final thought: relatives often hang out on the ward then think this qualifies them as authorities on what nurses do - again I would like to thank you for illustrating so eloquently [and in your own inimitable and unmistakable style] why this is not actually the case ;-)

I don't think my trust has yet figured out that more nurses on the general wards getting patients treated and out quicker would reduce A&E waiting times yet.

They short staff the wards and then have people walking around Accident and emergency with clipboards screaming at the staff down there for not getting patients sorted and in a bed in the target time frame.

I would like to thank you Anne for voicing the experiances you have which are almost uncanny of my current experiance on an acute medical ward (although some the end of the month I am to pack my stethoscope and sphyg and run like buggery to surgery and will excape some of it). You proberbly dont have this option.

Acute nursing problems and the media never go well. Tell a patient the facts of MRSA (Transient nature, naturally occuring on the hands and nose of the population, first isolated in 1960 etc) and the whole thing seems almost benign. I read the nursing journals and know that following the development of Pennicilin, in 1958 the Lancet reported some resistance. So Methicillin was developed, then in 1960 there was found to be methicillin resistance in staff. Aureous.

Read the Sun, Mirror, or any other paper, and they pain a picture which is grossly distorted and perverted, who will cite dirty hospitals having killer superbug caused by nurses not washing their hands spreading this drug resistant germ.

Drug resistant eh sunny? So Tiecoplanin, Colomycin, Vancomycin, and the other Macrolides are what exatcly?

No wonder nurses leave. I like to think I enter the profession in the spirit of starting as I mean to go on. So cynical, fed up and near burt out.

nursing student - Fleming warned as early as 1945 that misuse of penecillin would lead to selection and propagation of mutant forms of bacteria resistant to antibiotics [he grew such pathogens in the lab].Levy [2002] The Antibiotic Paradox, p7-8.

The UK as you know has some of the highest rates of MRSA in Western Europe [44% as compared to 1% in the Netherlands according to some reports].

Reasons cited for this disparity include;*Larger pool of asymptomatic carriers of in the community [resevoirs in nursing homes, etc]. *UK has some of the highest bed occupancy rates in Europe [90+% in most hosptals].*Increasingly rapid turnover of inpatients, as hospitals become more "efficient".*Over-reliance on agency staff who may be less likely to comply with infection control measures ?*Increasingly dificult to admit patients to specialty wards [any bed will do, 4hr A&E target, etc].*Insufficient side rooms.

But why focus on infrastructure and policy when the media [and Joe Bloggs] can put the boot in on a few gossiping, chocolate addicted nurses - welcome to hell;-)

@ the A&E charge nurse: Thanks for the welcome to hell. At least with the cutbacks the furnaces are not as hot anymore lol.

It's true about our rates and the turnover. Still, when was reality ever accuratly reflected in the official written word?

As for "Increasingly dificult to admit patients to specialty wards [any bed will do, 4hr A&E target, etc]". Yup, thats right. I am on the so called ID ward of the hospital... so naturally it full of acute admissions with falls, dementia and other nursing home fodder. Good job avian flu, Malaria or whatever pandemic is going to wipe us out this week in the Daily Mail has not shown up. With only 5 side rooms we will be a tad stretched if hundreds of patients need isolating.

Proberbly why so many people leave nursing. They want to do it but enter then think "Hang on, I've done something wrong here".

This is exactly why I left the hospital and went into hospice nursing. Labor and delivery is still my first love but there was so much mandatoried overtime I never saw my family and I had no time to do anything for myself. Then the management upped our staffing ratios (which I now realize the British nurses woould kill for and I feel guilty)so we'd have 2 active patients at a time or a patient with a dead baby and one with a live baby or 6 postpartum patients all wanting help breastfeeding, etc. It was killing me.

Now I drive to someone house, sit with them and have a chance to really listen, solve problems and tie up loose ends. It's not perfect, but it's satisfying.

Hi I am a fairly new RN I worked in the ICU for a year and a half and got burnt out. The lack of support from my collegues (most of them foreign nurses) and bad attitudes from my "assistants" is what did it for me. Not to mention the abuse from my patients and their families. It is sad it is nothing like I had imagined it to be. I thought I would actually have time to spend with my patients and "nurse" them back to health. Instead, I was constantly on the run just trying to keep up with passing out my medications and hanging my IV drips without making a horrible mistake because of the lack of time and lack of staff. The stress level I felt for those 12 to 13 hour shifts was unbearable. I would even have nightmares. I don't know what is going to happen to us when we get sick in the future without RNs at the hospitals. I empathize and my heart goes out to every bedside nurse out there. I luckily got a case management position so I still practice nursing but from an administrative stand point. Believe me after doing bedside nursing I will never, ever take my job for granted. If I could survive the hell that I survived I can do any job. And do it with a smile.

In an atmosphere if universal deceit telling the truth is a revolutionary act. George Orwell.

Why has Nursing Care Deteriorated

Good nurses are failing every day to provide their patients with a decent standard of care. You want to know what has happened? Read this book and understand that similiar things have happened in the UK. Similiar causes, similiar consequences. And remember this. The failings in care have nothing to do with educated nurses or nurses who don't care. We need more well educated nurses on the wards rather than intentional short staffing by management.

About Me

I am a university educated registered nurse. We had a hell of a lot of hands on practice as well as our academic courses. The only people who say that you don't need a brain or an education to be an RN are the people who do not have any direct experience of nursing in acute care on today's wards. I have yet to meet a nurse who thinks that she is above providing basic care. I work with nurses who are completely unable to provide basic care due to ward conditions.
I have lived and worked in 3 countries and have seen more similarities than differences. I have been a qualified nurse for nearly 15 years. I never used to use foul language until working on the wards got to me. It's a mess everywhere, not just the NHS.
Hospital management is slashing the numbers of staff on the ward whilst filling us up with more patients than we can handle... patients who are increasingly frail. After an 8-14 hour shift without stopping once we have still barely scratched the surface of being able to do what we need to do for our patients.

Quotes of Interest. Education of Nurses.

Hospitals with higher proportions of baccalaureate-prepared nurses tended to have lower 30-day mortality rates. Our findings indicated that a 10% increase in the proportion of baccalaureate prepared nurses was associated with 9 fewer deaths for every 1,000 discharged patients."...Journal of advanced nursing 2007

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level.

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania's Center for Health Outcomes and Policy Research found that patients experienced significantly lower mortality and failure to rescue rates in hospitals where more highly educated nurses are providing direct patient care.

Evidence shows that nursing education level is a factor in patient safety and quality of care. As cited in the report When Care Becomes a Burden released by the Milbank Memorial Fund in 2001, two separate studies conducted in 1996 - one by the state of New York and one by the state of Texas - clearly show that significantly higher levels of medication errors and procedural violations are committed by nurses prepared at the associate degree and diploma levels as compared with the baccalaureate level.

Registered Nurse Staffing Ratios

International Council of Nurses Fact Sheet:

In a given unit the optimal workload for a registered nurse was four patients. Increasing the workload to 6 resulted in patients being 14% more likely to die within 30 days of admission.

A workload of 8 patients versus 4 was associated with a 31% increase in mortality. (In the NHS RN's each have anywhere from 10-35 patients per RN. It doesn't need to be this way..Anne)

Registered Nurses in NHS hospitals usually have between 10 and 30+ patients each on general wards.

Earlier in the year, the New England Journal of Medicine published results from another study of similar genre reported by a different group of nurse researchers. In that paper, Needleman et al3 examined whether different levels of nurse staffing are related to a patient’s risk of developing complications or of dying. Data from more than 5 million medical patient discharges and more than 1.1 million surgical patient discharges from 799 hospitals in 11 different states revealed that patients receiving more care from RNs (compared to licensed practical nurses and nurses’ aides) and those receiving the most hours of care per day from RNs experienced fewer complications and lower mortality rates than those who received more of their care from licensed practical nurses and/or aides. Specifically for medical patients, those who received more hours per day of care from an RN and/or those who had a greater proportions of their care provided by RNs experienced statistically significant shorter length of stay and lower complication rates (urinary tract infections, gastrointestinal bleeding, pneumonia, cardiac arrest, or shock), as well as fewer deaths from these and other (sepsis, deep vein thrombosis) complications

•Lower levels of hospital registered nurse staffing are associated with more adverse outcomes such as Pneumonia, pressure sores and death.
•Patients have higher acuity, yet the skill levels of the nursing staff have declined as hospitals replace RN's with untrained carers.
•Higher acuity patients and the added responsibilities that come with them increase the registered nurse workload.
•Avoidable adverse outcomes such as pneumonia can raise treatment costs by up to $28,000.
•Hiring more RNs does not decrease profits. (Hospital bosses don't understand this. They think that they will save money by shedding real nurses in favour of carers and assistants. The damage done to the patients as a result of this costs more moneyi.e expensive deaths, complications,and lawsuits, and complaints....Anne)

Disclaimer

I know I swear too much. I am truly very sorry if you are offended. Please do not visit my blog if foul language upsets you. I want to help people. That is why I started this blog and that is why I became a Nurse. I won't run away from Nursing just yet. I want to stick around and make things better. I don't want the nurses caring for me when I am sick working in the same conditions that I am. Of course this is all just a figmant of my imagination anyway and I am not even in this reality. Or am I?Any opinions expressed in my posts are mine and mine alone and do not represent the viewpoint of the NHS, the RCN, God, or anyone else.